General FAQs

General Rhinoplasty FAQs from Our New Hampshire Practice, near Massachusetts

This page is dedicated to answering some of the most commonly asked general questions about rhinoplasty at our New Hampshire practice, near the Massachusetts border. Because we get so many different types of nasal surgery questions, we have additional FAQ pages on our site that are dedicated to the following topics:

In addition, you can find a series of frequently asked questions and answers about revision surgery on our secondary rhinoplasty page. If you have additional questions or would like to schedule a consultation, during which Dr. Mark Constantian can assess your specific situation, please do not hesitate to contact our office.

The answer to that depends upon the shape of the bump and the balance of the nose. If the bump is small and all of the parts of the nose are in very good position (this is uncommon) the correction is very simple and involves only smoothing the bump. However, the lower part of the bump, which is cartilage (not bone) supports the sides of the nose, and so if the bump is high enough that the “roof” of the cartilaginous arch will be opened, I need to place special grafts along the sides of the septum so that the airway remains stable after the rhinoplasty is complete. In addition, the areas of the nose are very interconnected, so that a change in one area can make an absolute or apparent change in another area. For example, reducing a high bump can make the nose longer or shorter (which means a secondary adjustment so that things will look right). Changing the height of the bridge can also change the apparent size of the lower nose, once again requiring some secondary adjustment so the nose achieves its optimal balance.

Finally, a bump is often accompanied by a tip that doesn’t have very good shape, and tip surgery complicates things further.

If the nasal skin is very thick, it will not shrink to a smaller size, but that does not mean that the nose cannot be made into a better shape, that the breathing cannot be improved or that the nose cannot even be made to look “smaller” by putting it into better balance. This rhinoplasty approach requires a combination of reducing the large parts of the skeleton and adding to areas that are small or poorly shaped to create good contour and the appearance of refinement.

Often, whether there is a history of injury or not, an unflattering nasal shape is the combination of areas that are too high or too low, too large or too small. Put simply, the treatment involves removing or reshaping areas that are too large, and supporting or building up areas that are too small to make the nasal shape straighter and better and to support the airway. How this is done depends on what has happened to your nose so far and what you would like to achieve. Frequently there are several possible solutions, some more complicated than others, which I could describe and illustrate for you after your rhinoplasty examination at my New Hampshire office, near Massachusetts, so that you can decide what, if anything, you wish to do.

Septum and valves: Although the “deviated septum” is what most people think of when they think of a blocked nose, the strength of the sidewalls is also very important, and my research since 1991 indicates that the valves (in the sidewalls) are probably more important to good nasal airflow than a straight septum. In fact, I see many rhinoplasty patients who have already had a septoplasty and still can’t breathe because the sides collapse. If the sides are too narrow or the cartilages so soft that they collapse on inspiration, the airway will be poor even if the septum is straight.

The answer, thus, depends on the site of the problem. On most patients, I will straighten the septum and support the sides, because that gives a superior result to simply straightening the septum. Some patients have already had a good septoplasty and I just need to stiffen the sides, in which case I can use septal cartilage if it is present or ear cartilage if it is not.

Turbinates: Turbinates warm and humidify the air and they are very sensitive to the environment: If you have hay fever, it is the turbinates that swell most and block your nose. When you have a cold, it is the turbinates that block the airway in response to the viral infection. In an obstructed airway, however, the turbinates also grow too large, not because they are abnormal, but as a result of an abnormality elsewhere (for example, the septum or valves). If the turbinates are not the primary culprit, I am much more conservative when treating them than if they are abnormal in some way themselves.

Too much turbinate surgery can create a chronic runny nose or a sense of chronic stuffiness. Therefore, I reduce turbinate size in less than five percent of patients. The great majority of the time I move the turbinates out toward the sidewalls so they don’t take up as much space, which allows them to retain all of their function and yet not block the airway.

Most patients hate the idea of anything being put in their noses, and patients who have had packing before hate the idea even more. I saw a man some years ago who had had a rhinoplasty 30 years before. He could not remember the name of the surgeon or the hospital or exactly what was done; all he could remember was the day they took the packing out.

Unfortunately, this is too common an experience, and so I have done everything I can to make the packing easier. Packing is necessary because it is like an internal splint to hold everything I have done in position: to support the grafts, to keep the airway clean and free of crust, and to immobilize the septum. However, packing does not need to be miserable.

First, I put tubes in each airway (about the size of a drinking straw), which allows most patients to breathe through the nose, at least for a few days. Sometimes the tubes stay open all week and sometimes they crust over after a few days, but it is still better than nothing. Secondly, I do not use one long strip of packing, but short packs, each about two inches long, that I layer one on top of another and then suture them to the tubes (not to the patient). Thus, the packing cannot move in or out and the tubes cannot move in or out. At the end of a week, the lining is healed and is secreting mucous so the packs have become slippery and slide out easily. Unlike trying to remove the packs at 24 – 48 hours when everything is still fresh from surgery, removing the packing at seven days is not painful.

Packing is necessary for success in the kind of surgery that I do; but I have used this system for almost 30 years and it is reliable and much more comfortable for the patient than the traditional methods.

Yes. One of the advantages of the closed approach to rhinoplasty is very limited dissection, which means that I don’t have to expose anything I am not going to correct. It is possible, therefore, to make limited changes without the risk to other areas. However, remember also that the nose is a complicated structure, so sometimes it is necessary to change two or three areas to make it look as if only one area has been altered.

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If you would like to schedule a consultation, or if you have additional questions about rhinoplasty, please contact our New Hampshire practice, serving Massachusetts and beyond.